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Pre-Existing Conditions By Submitted to the Division of Graduate Studies in partial fulfillment of the requirements for MBA 512: Health Policy and Law Shepherd University April 13, 2010 Abstract Imagine paying $500, $600, $700, or $1,000 monthly for health care insurance only to realize these payments were for naught. The health care insurance provider that received these monthly installments has decided whatever is ailing you will not be covered due to a pre-existing medical condition.

What if you couldn’t have the luxury of health care insurance at all due to the basis the health care insurance provider has concluded you have a pre-existing medical condition? These are the dilemmas facing millions of Americans today in the current health care system. America’s health insurance companies exist to make a profit and not for the general well being of the persons they insure. To achieve a profit the health insurance companies must deny coverage claims when Americans need coverage the most or not cover these individuals in the first place.

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This is a problem that the United States is addressing, or trying to address, in heated debate on Capitol Hill. Many of our Republican politicians want to continue with the status quo of the health care system while Democrats seek to eliminate pre-existing conditions altogether. The American public has come to recognize there has to be a major overhaul of the current health care system starting with pre-existing conditions. Pre-Existing Conditions Defined

The University of Pittsburg Medical Center defines a pre-existing condition as (University of Pittsburg Medical Center, 2011), “A medical condition that occurred before a program of health benefits went into effect”. The Henry J. Kaiser Family Foundation (Kaiser Family Foundation, 2011) breaks down further what exactly the definitions for health insurance companies are varied by state. Their define the breakdown as “some states use an objective standard allowing only those conditions for which someone actually received medical advice, diagnosis, care or treatment prior to enrollment to be counted as pre-existing.

Most states use a broader, prudent person standard, which also includes conditions that were never diagnosed, but which exhibited symptoms for which an ordinary prudent person would have sought medical advice, care or treatment”. The Kaiser Family Foundation’s market portability rules (Kaiser Family Foundation, 2011) has listed 21 states that require health insurance companies to use the prudent person standard, 18 states require the objective standard, while 10 states have no definition specification. Listed below are the state laws for group and individual insurance plans.

These laws are broken down into large, small and group insurance plans. Each group has the allotted amount of time a state can look back for a pre-existing condition from the start date of the policy and how long a pre-existing condition can be excluded by the policy given by The Kaiser Family Foundation market profitability rules by state (2011, 1). Maximum pre-existing condition exclusion period group plans Small Group Plans with 2 – 50 employees: Large Group Plans: 0 Months – Hawaii, Maryland, Michigan 12 months – 50 states and DC 3 Months – Kansas Months – California, Colorado, New Jersey, Massachusetts, New Mexico, Oregon, Rhode Island 9 Months – Indiana 12 Months – 36 remaining states and DC Maximum pre-existing condition look back period group plans Small Group Plans with 2- 50 employees: Large Group Plans: 0 Months – Hawaii, Maryland, Michigan 6 Months – 50 states and DC 6 Months – Kansas, New Hampshire Maximum pre-existing condition exclusion period individual plans 0 Months – Massachusetts, Oregon, New Mexico 9 Months – New Hampshire, Washington 2 Months – California, Colorado, Connecticut, Idaho, Kentucky, Maine, Maryland, Michigan, Mississippi, Montana, New Jersey, New York, North Carolina, North Dakota, Ohio, Pennsylvania, Rhode Island, South Dakota, Utah, Virginia, Vermont, West Virginia, Wyoming 18 Months – Minnesota 2 years – Alabama, Florida, Georgia, Illinois, Iowa, Kansas, South Carolina, Tennessee, Texas, Wisconsin 3 years – Hawaii 10 years – Indiana Unlimited – Alaska, Arizona, Arkansas, Delaware, DC, Louisiana, Missouri, Nebraska, Nevada, Oklahoma Maximum pre-existing condition look back period individual plans 3 Months – New Hampshire Months – Idaho, Kentucky, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Utah, Washington, Wyoming 12 Months – California, Colorado, Connecticut, Indiana, Louisiana, Maine, Maryland, Mississippi, North Carolina, South Dakota, Vermont, Virginia 2 Years – Florida, Illinois, West Virginia 3 Years – Montana, Rhode Island 5 Years – Alabama, Arkansas, Delaware, Iowa, Pennsylvania, Texas Unlimited – Alaska, Arizona, DC, Georgia, Hawaii, Kansas, Missouri, Nebraska, Oklahoma,

South Carolina, Tennessee, Wisconsin Types of Pre-Existing Conditions What constitutes a pre-existing condition is at best, vague and left to the health insurance provider to decide. David S. Hilzenrath of The Washington Post (David H, 2009) recovered documents from a consumer advocacy group, Consumer Watchdog about Pacificare medical underwriting guidelines of ineligible occupations which include: Stunt people, test pilots and circus workers, along with police officers, firefighters and migrant workers.

Pacificare also included persons needing automatic rejection from coverage as; being pregnant, expectant fathers, people receiving counseling within the past six months, and currently experiencing symptoms within the last 2 months where a physician has not been consulted. Consumer Watchdog (David S, 2009) also uncovered insurance provider Health Net’s and Blue Cross Blue Shield’s guidelines for persons who can be denied coverage or charged higher premiums for taking certain medications. Health Net’s disqualifiers include, Zyrtec, used for allergies, and Lamisil used for Toe Fungus.

Blue Cross Blue Shield’s included chronic tonsillitis, and varicose veins. The U. S. Department of Health and Human Services (HealthCare. gov, 2011) goes further into what health insurance providers deem pre-existing conditions which can make persons ineligible for coverage or charge higher premiums. “Some plans consider acne, asthma or high blood pressure a pre-existing condition. Others narrow the definition of pre-existing conditions to cancer or diabetes. Sometimes you might have totally recovered from a condition – like a past bout with depression – and it will still count against you”.

Currently health insurance providers are allowed to decide what best fits into their definition of what a pre-existing condition is. Since these definitions are so vague consumers may have paid premiums to providers for years and not realized they were not covered when they needed coverage the most. This is a way the health insurance companies ration healthcare to make a healthy bottom line. Faces of Pre-Existing Conditions The Huffington Post (Ivory, D, 2009) released an article about the sad truth of who is affected by pre-existing conditions.

The Huffington Post has funded a citizen journal report taking stories about persons being denied coverage. Christina Turner is one of the victims cited in the citizen journal report. Turner at age 45 had two men slip a knockout drug in her drink. She woke up on the side of a road with bruises and cuts all over her body. These are signs that Turner was raped. Turner took the precautions of a rape victim by having her health care provider prescribe her a month’s worth of anti-AIDS medication.

She never contracted HIV but was hassled by further complications of her rape. Turner lost her health insurance coverage and sought to find new coverage. Due to her taking the anti-AIDS medication Turner was denied coverage from several health insurance providers. The common answer the health insurance providers would advise Turner is if she can prove she did not contract HIV/AIDS she would be eligible for coverage in two to three years. Kimberly Fallon was another victim of rape in Huffington Post’s citizen’s journal report.

Fallon at age 38 was raped a year prior. While attending a hospital for the rape Fallon gave the nurse her medical history including a time she was raped in college 17 years prior. Later when she received the bill she was told by the nurse and the hospital’s billing department that he health insurance provider, Blue Cross Blue Shield declined to pay for the rape exam and for therapy and medication because she had been raped before. A woman from New Mexico explained on the journal report she suffered post-dramatic-stress disorder from a rape that happened in 2003.

Because of the rape she said many health insurance providers denied her coverage due to this pre-existing condition. She did not to use her name, not because she feared the man that raped her, but she feared if her group health insurance found out she was a prior rape victim her coverage would be dropped. Rape is not the only horror story of being denied coverage from health insurance companies as a pre-existing condition. Domestic violence is another reason a person can be denied. Ryan Grim of the Huffington Post (Grim, R, 2009) wrote an article, “When getting beaten by your husband is a pre-existing condition”.

Grim goes on to report eight states including the District of Columbia allow insurance companies to use domestic violence as a pre-existing condition. In the article Grim states, “Under the cold logic of the insurance industry, it makes perfect sense: If you are in a marriage with someone who has beaten you in the past, you’re more likely to get beaten again than the average person and are therefore more expensive to insure. Victims of domestic violence and rape continue to be victims under our current health insurance policies. They are victimized twice: Once by the assailant, twice by the health insurance provider.

Average Americans with Pre-Existing Conditions There isn’t any shortage of Americans with pre-existing conditions. As stated above, health insurance companies determine what a pre-existing condition is. The Department of Health and Human Services (DHHS) Secretary Kathleen Sebelius (Sebelius, 2011) released analysis on January 18, 2011 defining how many Americans have a pre-existing condition. In the report The DHHS stated that up to 129 million non-elderly Americans (50%) have a pre-existing condition like heart disease, high blood pressure, arthritis, or cancer.

These 129 million Americans would be at risk of losing health insurance or be denied coverage in the first place. Of the elderly population (ages 55 to 64) up to 86% of the population has a pre-existing condition. In the report 15% to 30% of Americans will develop a pre-existing condition in the next eight years. In a national survey 36% of individuals that tried to purchase an individual policy directly from an insurance company were turned down, charged more, or had a specific health problem that excluded them from the policy.

Another survey found that 54% of Americans were afraid if they became really sick they would be turned down by their health insurance provider. Affordable Health Care for America Act Bill HR 3962 On March 23, 2010 President Barack Obama signed into law the Affordable Care Act (HealthCare. Gov 2, 2011). The bill was introduced by Representative John Dingell, Democrat Michigan to the 111 Congress on October 29, 2009 and had six sponsors: Representative Robert Andrews, Democrat New Jersey, Representative George Miller, Democrat California, Representative Frank Pallone jr. Democrat New Jersey, Representative Charles Rangel, Democrat New York, Representative Pete Stark, Democrat California, and Representative Henry Waxman, Democrat California. The Affordable Health Care Act affects pre-existing conditions in several ways. Health plans that cover children age 19 and under, can no longer exclude or deny benefits based on a disability or health problem a child received before being covered. The new rule applies to individual and job covered health insurance plans issued after March 23, 2010.

The rule affects a health care plan as soon as it begins a plan year or policy year on or After September 23, 2010. In 2014 under the Affordable Care Act (Sorian, R, 2011), health insurance providers will no longer have the freedom to determine what a pre-existing condition is. Providers will no longer be able to carve out what they cover in their packaged benefits to ration who is eligible for coverage, charge higher fees for persons perceived as higher cost customers, put lifetime limits on benefits, or deny any person of any age coverage due to a pre-existing condition.

Insurers can no longer deny coverage of a mistake made while filing paperwork. The last line delivered to us by Richard Sorian, Assistant Secretary of Public Affairs, courtesy of the Affordable Care Act, “The Affordable Care Act is making sure that you have health coverage when you need it most, and is putting your health care where it belongs – in your hands, not in the hands of your insurance company”. There exists a time gap between when the Affordable Care Act eliminates pre-existing conditions for children (2010), and the rest of the population (2014).

Under the act adult persons with a pre-existing condition in every state will now be able to purchase health care insurance through a temporary pre-existing condition insurance plan. Information to find out if a person is eligible for the pre-existing health care plan and in what state can be found on HealthCare. gov or by calling 1-866-717-5826. The 112th Congress of the United States (House. gov, 2011), introduced a bill sponsored by House Majority Leader Eric Cantor, Republican Virginia. The bill’s purpose is to repeal health care reform signed by President Obama.

The bill is officially is called, “To repeal the job-killing health care law and health care-related provisions in the Health Care and Education Reconciliation Act of 2010”. The Democrats held the majority of seats in the 111th Congress while the Republicans hold the majority of seats in the current 112th Congress of the United States. The Affordable Health Care for America Act is far from being written in stone. Elections for the President of the United States are being held in 2012 and depending on what political party hold the executive chair (Democrat or Republican), this act can be amended or repealed.

In 2012, 33 out of 100 senatorial seats are up for election along with all the House of Representatives seats. The nature of the health care debate can be changed dramatically in 2012 depending on who becomes the next president of the United States and who wins power in The House and The Senate. Affordable Health Care for America Act Bill HR 3962 What Should Happen The Bill should stay as written. The only downside of the bill is the full effect of the bill does not kick in until 2014. The full elimination of pre-existing conditions has to start right away.

The richest, most powerful nation in the world should be able to cover the sickest individuals who need coverage the most. Instead what we have is a system that denies coverage for the sick to make a profit. In 2007 Los Angeles staff Lisa Girion (Girion, 2007), wrote an article revealing how one particular insurance company paid out bonuses to drop health insurance policy holders. Woodland Hills-based Health Net Incorporated’s goals and measurements for performance review based their employee review on financial measures.

Here is how the financial goals and performance measures are laid out: 1. “Goal – contribute to financial integrity of IFP product line through diligent investigation and detection of applicant misrepresentation. Performance measure – achieve a monthly average of 15 IFP contract rescissions / monthly average was 22. 9 rescissions”. 2. Goal – “Achieve first – year target IFP MCR through the application of department underwriting standards. Performance measure – actuarial estimate of first year MCR as compared to target assumed in rate development”.

Health Net saved $35. 5 million in medical expenses by rescinding about 1600 policies between 2000 and 2006. They paid the senior analyst $20,000 in bonuses during this period in part because of the cancelation of policies. Girion, goes on to say these bonuses are typical for health insurance companies. Most health insurance companies have departments whose main goal is to terminate policies. These bonuses for cancelling policies makes people work harder to cancel policies instead of working with the patient to pay for medical care.

This is why the Affordable Care Act must remain as is for pre-existing conditions For the disposal of pre-existing conditions There are many Americans that believe pre-existing conditions should be terminated in the American health care system. Right now there are too many Americans not being covered when they need coverage the most. Pre-existing conditions are one part of the health care system that should not be used to pursue capitalism. People should not be denied coverage so health insurance companies can create higher profits.

In February, 2010 the American leaders took part in a live, on air for television health care summit and the discussion on pre-existing conditions became a talking point. Senate Majority Harry Reid, Democrat Nevada told a story about pre-existing conditions (Reid, 2010) “I want to start by talking about a young man by the name of Jesus Gutierrez. He works hard. He has a restaurant in Reno, Nevada. He had everything that he wanted, except a baby. He had health insurance. He had employees that liked him. But he was fortunate — they were going to have a baby and it was going to be a little girl.

And the baby was born, and in just a few minutes after the birth of that baby, he was told that the baby had a cleft pallet. ‘But that’s okay,’ he was told. ‘We can take care of that. ’ And they did. They did some surgery on the baby; he was happy — that is, Jesus was happy — until he got his mail four months later, opened the envelope, and the insurance company said, ‘We didn’t realize that your baby had a preexisting disability. We’re not covering the $90,000 in hospital and doctor bills you’ve already run up. ’ So he’s trying to pay that off.

The baby needs a couple more surgeries. This shouldn’t happen to anyone in America”. During the same health care summit Representative from New York, Democrat Louise Slaughter had this to say on health insurance companies dropping people due to pre-existing conditions (Slaughter, 2010), “It is cruel, it is capricious and it is done only to enhance the bottom-line. ” House Minority Leader, Nancy Pelosi, Democrat California had this to say on the Government’s website, house. gov about women and pre-existing conditions (Pelosi, 2011). For too long, women have faced discrimination in the health insurance market — often being charged substantially higher premiums for the same coverage as men. With the passage of comprehensive health insurance reform no longer will being a woman be considered a pre-existing medical condition”. President Barack Obama was personal when he shared his thoughts at a speech in June 2009, at a speech to the American Medical Association about pre-existing conditions. The President stated, “We need to end the practice of denying coverage on the basis of preexisting conditions.

The days of cherry-picking who to cover and who to deny, those days are over. I know you see it in your practices, and how incredibly painful and frustrating it is — you want to give somebody care and you find out that the insurance companies are wiggling out of paying. I’ll never forget watching my own mother, as she fought cancer in her final days, spending time worrying about whether her insurer would claim her illness was a preexisting condition so it could get out of providing coverage.

Changing the current approach to preexisting conditions is the least we can do — for my mother and for every other mother, father, son, and daughter, who has suffered under this practice, who’ve been paying premiums and don’t get care. We need to put health care within the reach for millions of Americans” Democrats are not the only people wanting to end pre-existing conditions but many Republican leaders would like to end this practice also.

The House Majority Leader, John Boehner, Republican from Ohio, has listed on his personal website (Boehner, 2011), “Quality health coverage must exist for every American, regardless of pre-existing health conditions”. When Louisiana Governor Bobby Jindal, Republican, parents arrived in the New World his mother was 4 ? months pregnant. Just the same as the President, Governor Jindal was personal on the issue of ending pre-existing conditions. Jindal stated, (Jindal, 2009). “I was what folks in the insurance industry now call a ‘pre-existing condition’”.

Finally, who wants to end pre-existing conditions? Political parties can fight back and forth on the issue of pre-existing conditions but there is only one opinion that matters; the opinion of the American people. The Kaiser Family Foundation created a health tracking poll in 2009. The poll consisted of many elements of health care and health care reform. Many of the issues had close results especially depending on what political party the person voting was affiliated with. There was one outlier of the poll and that was pre-existing conditions.

The results of the poll are as follows (Kaiser Family Foundation Poll, 2009): 80% were in favor of ending pre-existing conditions while 17% of the people wanted to keep pre-existing conditions. The 80% of the people that wanted to end pre-existing conditions were then asked: “What if you heard this requirement might mean that healthier people would end up paying somewhat more for their health insurance than they do now, while sicker people would pay somewhat less”? The answer then changed from 80% in favor to 56% now in favor of ending pre-existing conditions.

The 17% that wanted to keep the pre-existing condition law was asked: “What if you heard that some people with very expensive illnesses like cancer would have no way of getting insurance otherwise? Their answer changed from 17% to 86% wanting to end the pre-existing condition laws. The answer to the question above: Who wants to end pre-existing conditions? The answer is the American people! For keeping the status quo on pre-existing conditions Finding people willing to state they are opposed to ending pre-existing conditions is a somewhat hard task to take on.

The truth is people do not want to go on record saying they are perfectly ok with denying sick people coverage that are paying or want to pay for health insurance. Unfortunately, although hard to find these people do exist. Representative Steve King, Republican, Iowa, stated (Wing, 2011) he was not worried about eliminating the pre-existing condition clause in the Affordable Health Care Act. Representative King went on to say, “I actually don’t think it would be met with tremendous backlash. There are Republicans that support those ideas and we start tomorrow the process of replacement of Obamacare”. It will not work for us to say there’s a certain component of Obamacare that has some merit and so therefore we want to leave that in place and repeal the rest. This is too many pages, it’s too cluttered, and it’s too big an argument to allow it to turn on one or two minor things”. It’s hard to believe that Representative King would insist that pre-existing conditions were a minor thing. Especially since the Kaiser Poll stated above suggests pre-existing conditions are the thing Americans overwhelmingly agree must be changed.

Arkansas republican Governor Mike Huckabee compares pre-existing conditions with burning houses. In 2010 Huckabee at the Value Voters Summit shared his thoughts on pre-existing conditions (Huckabee, 2010): “It sounds so good, and it’s such a warm message to say we’re not gonna deny anyone from a preexisting condition. ” “ “Look, I think that sounds terrific, but I want to ask you something from a common sense perspective. Suppose we applied that principle [to] our property insurance. And you can call your insurance agent and say, “I’d like to buy some insurance for my house. He’d say, “Tell me about your house. ” “Well sir, it burned down yesterday, but I’d like to insure it today. ” And he’ll say “I’m sorry, but we can’t insure it after it’s already burned. ” Well, no preexisting conditions. ” Mike Huckabee is bringing up a very valid point. What is going to keep people from only purchasing health insurance when they need it and dropping the coverage when they are healthy? This question is being asked by several Republicans and the Democrats answer is to mandate health insurance.

The debate on this topic is early and fierce debate on the issue will lead America in the 2012 elections. Professional Health Organizations’ stance on pre-existing conditions There are many things to debate during the health care reform process but pre-existing conditions are not one of them. Debates can consist of the cost of pre-existing conditions for insurance companies but for health care professionals, there beliefs mirror each other. They all want to end pre-existing conditions. Below is a list of professional organizations and a statement of their beliefs regarding pre-existing conditions.

American Medical Association’s Advocacy and policy (American Medical Association, 2011); Insurance market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions or due to arbitrary caps”. Asthma and Allergy Foundation of America’s Public policy issues (Asthma and Allergy Foundation, 2011); ” We support health care that covers everyone, curbs costs responsibly, abolishes exclusions for pre-existing conditions, eliminates lifetime caps, and ensures long-term and end-of-life care”.

National Patient Advocates Foundation’s patient-centered health care reform solutions (national Patient Advocates Foundation, 2009); “Eliminate pre-existing condition exclusions and waiting periods in all private and public insurance plans”. American Psychiatric Association’s endorsement of HR 3200 (American Psychiatric Association, (2009), “Blocking insurance discrimination based on individuals’ health status and pre-existing conditions”. Maine Medical Association testimony (Maine Medical Association, 2010), “Insurance market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions”.

Nevada State Medical Association’s strategic legislative plan and strategy (NMSA Commission on Governmental Affairs, 2007); ” NSMA supports legislation either: to expand the existing reinsurance risk pool created for the “Health Insurance Portability and Accountability Act”; or, to create a new risk pool for the purpose of providing insurance coverage for “medically uninsurable” people having preexisting conditions which exclude them from regular insurance coverage”. Texas Medical Association’s guiding principles for health system reform (Texas Medical Association, 2009); “We applaud the authors of H.

R. 3200 for taking steps such as outlawing coverage denials for preexisting conditions”. North Dakota Medical Association statement of prescribe reforms (North Dakota Medical Association, 2010); “We need insurance reforms that eliminate barriers to robust competition in the private insurance market, eliminate exclusions for pre-existing conditions, and assist people who cannot afford private health insurance coverage to purchase coverage”. This is just a small list of the hundredths of professional health care organizations that want an end to pre-existing conditions.

There may be an organization in America that wants to keep pre-existing conditions in health insurance policies but finding them is near impossible. If they are out there their voices are not loud enough, for whatever reason, to put their beliefs in writing and place them on the Internet. Pre-Existing Policy Pre-existing conditions need to end. Health care reform has many obstacles but the true obstacle is money. Health insurance providers stand to lose millions the moment they can no longer ration health care. Money is the reason References American Medical Association (2011). AMA. com. Retrieved from ttp://www. ama-assn. org/ama/pub/about-ama/our-people/member-groups- sections/resident-fellow-section/advocacy-policy/policy-success. page American Psychiatric Association (2009). Medical News Today. Retrieved from http://www. medicalnewstoday. com/articles/164594. php Asthma and Allergy Foundation of America (2011). Aafa. org. Retrieved from http://www. aafa. org/display. cfm? id=5&sub=72 Boehner, J (2011). John Boehner. com. Retrieved from http://www. johnboehner. com/? p=234 Girion, L (2007). Los Angeles Times. Retrieved from http://www. latimes. com/business/la-fi-insure9nov09,0,4409342. story? rack=mostviewed- storylevel Grim, R (2009). The Huffington Post. Retrieved from http://www. huffingtonpost. com/2009/10/21/insurance-companies-rape-_n_328708. html HealthCare. gov 1 (2011). Timeline. Retrieved from http://www. healthcare. gov/law/timeline/index. html HealthCare. gov 2 (2011). U. S. Department of Health and Human Services. Retrieved from http://www. healthcare. gov/news/blog/preexistingcondition. html Hizelrath, D (2009). The Washington Post. Retrieved from http://www. washingtonpost. com/wpdyn/content/article/2009/09/18/AR2009091803501. html Huckabee, M (2010). Talking Points Memo DC.

Retrieved from http://tpmdc. talkingpointsmemo. com/2010/09/huckabee-opposes-insurance-for-people-with-pre-existing-conditions. php House. gov (2011). The U. S. House of Represenatives. Retrieved from http://rules-republicans. house. gov/Media/PDF/HR__-Repeal. pdf Ivory, D (2009). The Huffington Post. Retrieved from http://www. huffingtonpost. com/2009/10/21/insurance-companies-rape-n_328708. html Jindal, B (2009). Retrieved from http://blogs. wsj. com/health/2009/02/25/louisiana-gov-bobby-jindal-a-pre-existing-condition/ Kaiser Family Foundation (2011). Retrieved from http://www. statehealthfacts. rg/comparetable. jsp? typ=5&ind=355&cat=7&sub=87&sortc=2&o=a Kaiser Family Foundation Poll (2009). Retrieved from http://www. kff. org/kaiserpolls/upload/7990. pdf Maine Medical Association (2010). Mainemed. com. Retrieved from http://www. mainemed. com/legislation/testimony/ld1620_MacLean. pdf National Patient Advocate Foundation (2009). Npaf. org. Retrieved from http://www. npaf. org/images/pdf/news/npaf%20patient- centered%20health%20care%20reform%20solutions%20final. pdf NMSA Commission on Governmental Affairs (2007). Nevada State Medical Association. Retrieved from http://www. nsmadocs. rg/pdf/Leg%20Strategy_Comments. pdf North Dakota Medical Association (2010). Ndmed. Retrieved from mabu-ndmed. taopowered. net/image/cache/Op_Ed_10-09. pdf Obama, B (2009). Chicago Sun Times. Retrieved from http://blogs. suntimes. com/sweet/2009/06/obamas_ama_speech_as_delivered. html Pelosi, N (2011) House. gov. Retrieved from http://pelosi. house. gov/special-issues/women. shtml Reid, H (2010). MSNBC. Retrieved from http://www. msnbc. msn. com/id/35585513/ns/politics/ Sebelius, K (2011). Department of Health and human Resources. Retrieved from http://www. hhs. gov/news/press/2011pres/01/20110118a. html

Slaughter, L (2010). MSNBC Retrieved from http://www. msnbc. msn. com/id/35585513/ns/politics/ Sorian, R (2011). HealthCare. gov. Retrieved from http://www. healthcare. gov/news/blog/preexisting. html Texas Medical Association (2009). texmed. org. Retrieved from http://www. texmed. org/Template. aspx? id=7899 University of Pittsburg Medical Center (2011). Retrieved from http://www. upmc. com/HOSPITALSFACILITIES/FINANCIAL- SERVICES/Pages/billing-terminology. aspx Wing, N (2011). The Huffington Post. Retrieved from http://www. huffingtonpost. com/2011/01/19/steve-king-preexisting- conditions_n_811210. html


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